Moderate or intensive management of the active phase of second-stage labor and risk of urinary and anal incontinence: results of the PASST randomized controlled trial.

Pregnancy Female Humans Labor Stage, Second / physiology Delivery, Obstetric / methods Fecal Incontinence / epidemiology Postpartum Period Urinary Incontinence / epidemiology
anal delivery incontinence labor second stage urinary

Journal

American journal of obstetrics and gynecology
ISSN: 1097-6868
Titre abrégé: Am J Obstet Gynecol
Pays: United States
ID NLM: 0370476

Informations de publication

Date de publication:
11 2023
Historique:
received: 19 01 2023
revised: 12 07 2023
accepted: 20 07 2023
medline: 6 12 2023
pubmed: 28 7 2023
entrez: 27 7 2023
Statut: ppublish

Résumé

Incontinence occurs frequently in the postpartum period. Several theoretical pathophysiological models may underlie the hypothesis that different types of management of the active phase of the second stage of labor have different effects on pelvic floor muscles and thus perhaps affect urinary and anal continence. This study aimed to evaluate the impact of "moderate pushing" on the occurrence of urinary or anal incontinence compared with "intensive pushing," and to determine the factors associated with incontinence at 6 months postpartum. This was a planned analysis of secondary objectives of the PASST (Phase Active du Second STade) trial, a multicenter randomized controlled trial. PASST included nulliparous women with singleton term pregnancies and epidural analgesia, who were randomly assigned at 8 cm of dilatation to either the intervention group that used "moderate" pushing (pushing only twice during each contraction, resting regularly for 1 contraction in 5 without pushing, and no time limit on pushing) or the control group following the usual management of "intensive" pushing (pushing 3 times during each contraction, with no contractions without pushing, with an obstetrician called to discuss operative delivery after 30 minutes of pushing). Data about continence were collected with validated self-assessment questionnaires at 6 months postpartum. Urinary incontinence was defined by an ICIQ-UI SF (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) score ≥1 and anal incontinence by a Wexner score ≥2. A separate analysis was also performed among the more severely affected women (ICIQ-UI SF ≥6 and Wexner ≥5). Factors associated with incontinence were assessed with univariate and multivariable analyses. Among 1618 women initially randomized, 890 (55%) returned the complete questionnaire at 6 months. The rate of urinary incontinence was 36.6% in the "moderate" pushing group vs 38.5% in the "intensive" pushing group (relative risk, 0.95; 95% confidence interval, 0.80-1.13), whereas the rate of anal incontinence was 32.2% vs 34.6% (relative risk, 0.93; 95% confidence interval, 0.77-1.12). None of the obstetrical factors studied related to the second stage of labor influenced the occurrence of urinary or anal incontinence, except operative vaginal delivery, which increased the risk of anal incontinence (adjusted odds ratio, 1.50; 95% confidence interval, 1.04-2.15). The results of the PASST trial indicate that neither moderate nor intensive pushing efforts affect the risk of urinary or anal incontinence at 6 months postpartum among women who gave birth under epidural analgesia.

Sections du résumé

BACKGROUND
Incontinence occurs frequently in the postpartum period. Several theoretical pathophysiological models may underlie the hypothesis that different types of management of the active phase of the second stage of labor have different effects on pelvic floor muscles and thus perhaps affect urinary and anal continence.
OBJECTIVE
This study aimed to evaluate the impact of "moderate pushing" on the occurrence of urinary or anal incontinence compared with "intensive pushing," and to determine the factors associated with incontinence at 6 months postpartum.
STUDY DESIGN
This was a planned analysis of secondary objectives of the PASST (Phase Active du Second STade) trial, a multicenter randomized controlled trial. PASST included nulliparous women with singleton term pregnancies and epidural analgesia, who were randomly assigned at 8 cm of dilatation to either the intervention group that used "moderate" pushing (pushing only twice during each contraction, resting regularly for 1 contraction in 5 without pushing, and no time limit on pushing) or the control group following the usual management of "intensive" pushing (pushing 3 times during each contraction, with no contractions without pushing, with an obstetrician called to discuss operative delivery after 30 minutes of pushing). Data about continence were collected with validated self-assessment questionnaires at 6 months postpartum. Urinary incontinence was defined by an ICIQ-UI SF (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) score ≥1 and anal incontinence by a Wexner score ≥2. A separate analysis was also performed among the more severely affected women (ICIQ-UI SF ≥6 and Wexner ≥5). Factors associated with incontinence were assessed with univariate and multivariable analyses.
RESULTS
Among 1618 women initially randomized, 890 (55%) returned the complete questionnaire at 6 months. The rate of urinary incontinence was 36.6% in the "moderate" pushing group vs 38.5% in the "intensive" pushing group (relative risk, 0.95; 95% confidence interval, 0.80-1.13), whereas the rate of anal incontinence was 32.2% vs 34.6% (relative risk, 0.93; 95% confidence interval, 0.77-1.12). None of the obstetrical factors studied related to the second stage of labor influenced the occurrence of urinary or anal incontinence, except operative vaginal delivery, which increased the risk of anal incontinence (adjusted odds ratio, 1.50; 95% confidence interval, 1.04-2.15).
CONCLUSION
The results of the PASST trial indicate that neither moderate nor intensive pushing efforts affect the risk of urinary or anal incontinence at 6 months postpartum among women who gave birth under epidural analgesia.

Identifiants

DOI: 10.1016/j.ajog.2023.07.034 PMID: 37499991
pubmed: 37499991
pii: S0002-9378(23)00506-9
doi: 10.1016/j.ajog.2023.07.034
pii:
doi:

Banques de données

ClinicalTrials.gov
['NCT03018860']

Types de publication

Randomized Controlled Trial Multicenter Study Journal Article Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

528.e1-528.e17

Informations de copyright

Copyright © 2023 Elsevier Inc. All rights reserved.

Auteurs

Ninon Dupuis (N)

Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; Centre hospitalier universitaire (CHU) de Toulouse, Pole de Gynécologie Obstétrique, Hôpital Paule de Viguier, Toulouse, France. Electronic address: ninon.dupuis@aphp.fr.

Anne-Cécile Pizzoferrato (AC)

Department of Obstetrics and Gynecology, CHU Caen Normandie, Pôle Femme-Enfant, Caen, France.

Charles Garabedian (C)

CHU Lille, Department of Obstetrics, University of Lille, Lille, France.

Patrick Rozenberg (P)

Service d'Obstétrique et Gynécologie, Centre hospitalier intercommunal de Poissy-Saint-Germain-en-Laye, Poissy, France; Université Paris-Saclay, University of Versailles Saint-Quentin-en-Yvelines, Inserm, Equipe U1018, Epidémiologie clinique, Centre de recherche en Epidémiologie et Santé des Populations (CESP), Montigny-le-Bretonneux, France; Service d'Obstetrique et Gynécologie, Hôpital Américain de Paris, Neuilly-sur-Seine, France.

Gilles Kayem (G)

Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Service d'Obstétrique et Gynécologie, Hôpital Armand-Trousseau, Fighting Prematurity University Hospital Federation (FHU PREMA), Paris, France.

Thierry Harvey (T)

Hospital Group Diaconesses Croix Saint-Simon, Paris, France.

Laurent Mandelbrot (L)

AP-HP, Hôpital Louis Mourier, Service de Gynécologie-Obstétrique, Colombes, France.

Muriel Doret (M)

Obstetrics and Gynecology Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France.

Florent Fuchs (F)

Department of Obstetrics and Gynecology, CHU de Montpellier, Montpellier, France; Inserm, CESP U1018, Reproduction and Child Development Team, Villejuif, France; Desbrest Institute of Epidemiology and Public Health, University of Montpellier, Montpellier, France.

Elie Azria (E)

Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; Maternity Unit, Groupe hospitalier Paris Saint Joseph, Paris, France.

Marie-Victoire Sénat (MV)

AP-HP, Department of Obstetrics and Gynecology, Bicêtre Hospital, University Paris-Saclay, Le Kremlin-Bicêtre, France.

Pierre-François Ceccaldi (PF)

AP-HP, Service de Gynécologie-Obstétrique, Université de Paris, Hôpital Beaujon, Clichy, France.

Aurélien Seco (A)

Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; Clinical Research Unit Necker-Cochin, AP-HP, Paris, France.

Anne Chantry (A)

Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France.

Camille Le Ray (C)

Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; AP-HP, Maternity Port Royal, FHU PREMA, Paris, France.

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Classifications MeSH

questionsmedicales.fr › Phénomènes physiologiques des appareils urinaire et reproducteur › Phénomènes physiologiques de la reproduction › Reproduction › Grossesse › Moderate or intensive management of the active...
questionsmedicales.fr › Eucaryotes › Animaux › Chordés › Vertébrés › Mammifères › Eutheria › Primates › Haplorhini › Catarrhini › Hominidae › Humains › Moderate or intensive management of the active...
questionsmedicales.fr › Phénomènes physiologiques des appareils urinaire et reproducteur › Phénomènes physiologiques de la reproduction › Reproduction › Grossesse › Travail obstétrical › Début du travail › Second stade du travail › Moderate or intensive management of the active...
questionsmedicales.fr › Procédures de chirurgie opératoire › Procédures de chirurgie obstétrique › Accouchement (procédure) › Moderate or intensive management of the active...
questionsmedicales.fr › Maladies de l'appareil digestif › Maladies gastro-intestinales › Maladies intestinales › Maladies du rectum › Incontinence anale › Moderate or intensive management of the active...
questionsmedicales.fr › Phénomènes physiologiques des appareils urinaire et reproducteur › Phénomènes physiologiques de la reproduction › Période du postpartum › Moderate or intensive management of the active...
questionsmedicales.fr › États, signes et symptômes pathologiques › Signes et symptômes › Manifestations urologiques › Symptômes de l'appareil urinaire inférieur › Incontinence urinaire › Moderate or intensive management of the active...